BP situation - pg.2 | allnurses

BP situation - page 2

I just completed my orientation and was released so I am a newgrad LVN working fulltime days. I had a situation with a pt who has a Hx of HR of 60 at best he has bottomed out before around 45bpm when... Read More

  1. Visit  Overland1 profile page
    3
    After reading through the OP's description of the issue a couple of times, I cannot find anything that was done incorrectly. The patient's HR was ~60 prior to the med, and dropped to 48 occasionally with a SBP just under 100. A lot of folks "live" at those levels and do quite well. I still recall a very smart and experienced doc explaining this with the analogy of, "fifty is nifty," meaning if the HR is > 50, and all else is OK, then give the med. I have never seen any patient bottom out in any scenario as originally described.
  2. Visit  ♪♫ in my ♥ profile page
    0
    The MD is the one with the final call as to whether it's appropriate to give the med - unless you're certain that it's grossly unsafe - in which case you need to elevate the issue thorugh nursing and medical supervision - and be prepared to be taken to task for same.

    In this case, with the patient hemodynamically stable and the HR in the mid- to high-50's, once I'd reviewed the patient's status with the MD and clarified his/her desire to administer the medication, I would proceed (and, of course, carefully and thoroughly document the situation in real time).

    To answer your hypothetical: What about the converse? You decide to override the MDs judgement and an adverse outcome occurs...

    It is the MD's role to decide appropriate treatment so long as they have full knowledge of the patient's condition and status; making him/her aware of same is the RN's role.
  3. Visit  Anna Flaxis profile page
    1
    I would not have held Digoxin for a HR of 60. For a HR of 50 or less, I would definitely call the physician unless there were written parameters in place that stated otherwise. BP is not so much of a concern with digoxin, as it is a positive inotrope and slows AV nodal conduction and has no effect on SVR.

    In the absence of written parameters (i.e. hold for HR <50 and notify MD), if my patient were in that 50-60 range, I might wait a few minutes and come back and recheck HR a little while later. I'd also try to determine whether they've been on digoxin for a long time, or if this is a new medication for them. I'd look at VS trends, and of course, I'd assess them for any signs/symptoms of poor perfusion.

    If the person has been taking digoxin for 10 years, routinely has a HR of 50-60, and is tolerating their current HR without any adverse s/s, I'd give it. If this were a new medication for them, HR typically 60 or greater, and/or c/o dizziness, chest pressure/tightness, and/or dyspnea, I'd hold and call. And of course, if the patient is A&O, talk to them. Ask them how long they've been taking it and how it usually affects them.

    Medications like digoxin should have parameters attached. If there are no parameters and you have any concerns, call the physician and ask for them.
    cardiacrocks likes this.
  4. Visit  Sadala profile page
    0
    Quote from ~*Stargazer*~
    Medications like digoxin should have parameters attached. If there are no parameters and you have any concerns, call the physician and ask for them.
    Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

    Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

    It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.
  5. Visit  psu_213 profile page
    1
    None of those VS from the OP really "scare" me. I have seen "hold" parameters as low as "hold for HR<45" and "hold for SBP <90." In other words, for this pt, those VS might have been totally appropriate for those meds. Were these new meds or meds the pt was already on at home?

    I definitely think you handled it well. My only suggestions: 1. Chart the specific name of the doc/time of the conversation...example "Dr. Smith at BS at 1500. Alerted Dr. Smith of VS, HR 54 BP 98/63. Per Dr. Smith, digoxin given as ordered." 2. You may have done this anyway--make sure you chart VS regularly to show that you were monitoring the pt's response to the meds.
    Anna Flaxis likes this.
  6. Visit  psu_213 profile page
    0
    Quote from Sadala
    Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

    Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

    It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.
    I'm not sure of the norm in LTC. In the hospital I have pretty much always seen parameters for Beta blockers, ACE inhibitors, dig...and probably some others I can't think of right now.
  7. Visit  Standoe3 profile page
    0
    It depends on the hospital I think and the doctors. If the MD gives parameters with the order they are place in our computer system but if not they are not there.....as a student don't assume that parameters will be listed for all BP drugs and make it a habit to document the V/S with all BP meds that extra step will save ur license
  8. Visit  amoLucia profile page
    1
    I worked with one cardiac group where one practitioner had a standing rule. His cutoff was 50 bpm. He had a joke for us to get the pt to take a run about the bed to up the HR!

    All joking aside, this was a terrific cardiologist whom I trusted. (Even my parents consulted him, with my blessing.) He felt the drug's pharmokinetics were the desired therapeutic effect he was seeking for his pts. As long as the pt didn't have any other compromising negative symptoms, we were to give the dig. We all knew his care protocols and we WERE cautious and careful and we would call if we were concerned.

    Didn't run into the low HR pts too often, but his pts did well.
    turnforthenurseRN likes this.
  9. Visit  MotherRN profile page
    0
    What about LTC centers where the vitals of those taking cardiac meds are NOT assessed before giving the meds. The policies are to NOT assess except once in a while. What if the patient had a low reading and you gave meds to lower BP even more (without the benefit of knowing the VS) we could really hurt someone. Has anyone else worked where they DON"T assess vitals before administering vitals.
  10. Visit  azcna profile page
    0
    It's different in LTC because the primary nurse generally "knows" the residents pretty well health wise. You know who your brittle diabetics are, or the ones who always run high/always run low. You know who's B/P should be checked before meds (everybody gets checked before given dig though). Most of the residents have been on their beta-blocker or ace inhibitor for years. You can almost guess what their B/P and pulse will be, because they are relatively stable.
  11. Visit  RN2B123 profile page
    0
    How come in NS they teach you to "always" hold Dig/cardiac meds if HR is less than 60 bpm. At least that's what I was taught to do...was I misinformed then? They made such a big deal over it too...
  12. Visit  Anna Flaxis profile page
    0
    Quote from Sadala
    Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

    Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

    It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.
    I don't know if this is the norm for LTC, as I have never worked in that environment as an RN. However, at the hospital I worked at, the VS parameters were built into the order sets and protocols. If a physician wanted to order different parameters than what was in the protocol, they had to write an order. For example, I had a patient with severe aortic stenosis, and the cardiologist wanted the systolic blood pressure in the 80s. He had to write an order to supersede the protocol parameters, or he would have been getting several phone calls every day.
  13. Visit  cardiacrocks profile page
    0
    If ever I have a concern it is my practice to always check with the MD so good job. What I sometimes do is re-time the meds, so they aren't always given at once. Also, you stated the patient was on lasix, this med pulls potassium from the body, what amt of lasix and dig is the patient taking? Low k+ can cause dig toxicity, so you need to be careful, where you also replacing k+? Also you need to remember if this patient takes these meds everyday for some period of time then they are use to having a heart rate relatively low. I work on a cardiac unit a HR of 50-60 would not alarm me. Coreg and lisinopril can also lower HR. Either way you did the right thing, way to go!!


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